BOARD F DIRECTORS APPLICATION

Queensbury Emergency Medical Service prides themselves on accepting applications for Volunteering & Paid Staffing regardless of an applicant's race, color, creed, sex, marital status, disability, national origin, ancestry or place of birth.

I hereby apply for the Board membership in Queensbury EMS Inc. I understand that my acceptance in either of these corporations will be on a six month probationary basis. During which time my status may be terminated in accordance with the corporation by-laws or New York State Labor Laws. Any false statements or omissions made in this application will be considered sufficient cause for expulsion from the corporation upon discovery thereof.

I hereby authorize Queensbury EMS, or its representatives to make official inquiry of all persons, public and private companies, corporations, consumer reporting agencies, law enforcement agencies, state licensing and certifying agencies and medical advisors of this corporations to supply all information concerning my character, current and prior employment or membership verification, general reputation, personal characteristics and mode of living and furnish reports thereon.

If I am accepted as a Board Member by my peers, I will follow the operating rules as adopted and the by-laws as they may be amended in the future. I will agree to submit to physical and medical examinations at the option and expense of the corporation and also agree that the examining physician will disclose to the corporation or its representatives, the results of such examinations.

In connection with my application for a Board Seat with Queensbury EMS, I understand that consumer reports, which may contain public record information, may be requested and obtained. These reports may include information related to my previous driving record including court actions, citations, license suspensions and revocations as well as checking the NYS Sex Offenders Registry.

I HEREBY AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED TO FURNISH THE ABOVE MENTIONED INFORMATION

I have the right to obtain information as to the name, address and phone number of any agency providing such information and further, may request of that agency, upon proper identification, the nature and substance of all information in its files on me at the time of my request, including all sources of information, as well as, the recipients of any reports on me which that agency has previously furnished within the two (2) year period preceding my request.

YOUR CART

Board Of Directors

APPLICANT DEMOGRAPHICS

QUALIFICATIONS

REFERENCES

QUESTIONAIRE

AFFIRMATION